Deprescribing: The Solution to Irrational Polypharmacy

Transcription

1 CAPA Annual Conference Victoria, BC October 21, 2018 Deprescribing: The Solution to Irrational Polypharmacy Thomas L. Perry MD, FRCPC UBC Therapeutics Initiative

2 Faculty/Presenter Disclosure Thomas L. Perry MD, FRCPC No relationships with commercial interests I have consulted to plaintiffs in class action lawsuits and litigation against pharmaceutical manufacturers for fraudulent, illegal or inappropriate marketing Mitigating Potential Bias I try to seek truth and be sure what I say could withstand cross-examination: Honesty is the best policy. 2

3 Therapeutics Initiative Independent academic group at UBC Anaesthesiology, Pharmacology & Therapeutics Ministry of Health grant to UBC MDs, pharmacists, epidemiologists Students/visitors welcome BC developed an evidence-based Pharmacare starting 1995 and helped start Common Drug Review 3

4 Practical tricks of the trade 1. Rank medication list quickly by priority: probably useful Irrelevant or uncertain probably/potentially harmful 2. Recognize likely drug interactions (kinetic or dynamic); avoid potentially dangerous ones e.g. multiple drugs that slow heart rate, or impair kidney function 3. Use T ½ elim to plan safe deprescribing see examples 4. Develop strong reflexes against: unsupported, impractical, or potentially dangerous prescriptions originated by specialists who don t really know the patient. 4

5 How? 3 cases to prove that anyone can: 1. organize a drug list logically, for easier review. 2. consider independently a deprescribing strategy. 3. Cope with uncertainty and user/family objections to discontinuing drugs DESPITE pressures we all face that encourage inertia or worse: Guideline-based medicine - often based on evidence not relevant to our patients Potentially worsened by EMR. 5

6 Case 1: 67 y/o woman referred Sept Video will be shown live DM2, treated hemochromatosis Chronic rotator cuff injuries Started morphine 2002 at WCB rehab Referred re appropriateness of morphine 70mg/d (stable dose)??? Also treated for depression & insomnia 6

7 Medication list (alphabetical) 1. Canagliflozin 300mg/d 2. Celecoxib 200mg/d 3. Compounded cream (amitriptyline, ketamine, etc.) 4. Cyclobenzaprine 10mg/d 5. Gliclazide MR 30mg/d 6. Insulin glargine 30units bid 7. Metformin 500mg bid 8. Mirtazapine 30mg/d 9. Morphine SR 10/20mg bid 10. Nabilone 2mg/d 11. Quinine sulfate 300mg hs 12. Venlafaxine XR 150mg/d 7

8 Medication list (rearranged comments?) For pain For depression/sleep For diabetes 1. Canagliflozin 300 mg/d 2. Gliclazide MR 30 mg/d 3. Insulin glargine 30 units bid 4. Metformin 500 mg bid 8

9 Her concerns: Morphine 70mg/d worked really well for right shoulder pain from nerve injury, but cut to 30mg/d due to CPSBC standard Physiotherapy made shoulder worse Zopiclone 3.75 mg worked really well for sleep, but violated standard A1C 10.4% last year, but CBG usually 5-7, almost always < 11, highest was 17 Fears diabetes an orthopedic surgeon had refused to operate on her foot ( because it won t heal ) Drugs expensive: $4,000/y out of pocket! 9

10 Husband s concerns: She stays up late at night, writing the story of their foster children She then has trouble getting to sleep, but sleeps in - long after he s awake 10

11 Wake up time! can T ½ elim or knowing the clinical pharmacology help? For pain? 1. Morphine SR 10 mg, 20 mg 2. Nabilone 2 mg hs 3. Compounded cream to arm 4. Cyclobenzaprine 10 mg/d Your chance to shine! What is the worst that can happen if we stop any of these? For depression/sleep? 1. Venlafaxine XR 150 mg hs to relax at night 2. Mirtazapine 30 mg hs 3. Quinine sulfate 300 mg hs stops cramps For diabetes 1. Canagliflozin 300 mg/d 2. Gliclazide MR 30 mg/d 3. Insulin glargine 30 units bid 4. Metformin 500 mg bid 11

12 What would YOU suggest for this woman? Drug Indication? Toxicity? Continue/ adjust? Morphine SR 30 mg/d Nabilone 2 mg/d Shoulder pain Stop? Celecoxib 200 mg/d Post foot Sx Autostop Cyclobenzaprine 10 mg/d Venlafaxine XR 150 mg/d Mirtazapine 30 mg/d Quinine 300 mg/d Canagliflozin 300 mg/d Gliclazide MR 30 mg/d Insulin glargine 30 units bid Metformin 500 mg bid 12

13 16 month follow-up could this be one of YOUR patients? We will see what happened so far, and whether you approve or not Will you be surprised, or not? 13

14 Did YOU learn anything from this case? Can you trust your own clinical logic? More caution about starting any long term drug? How to decide about rate of taper? Nothing? Notes: 14

15 Deconstructing language can help! She will definitely benefit from an antidepressant??? (probability from RCT 10%) His diabetes should be treated aggressively. Should we be aggressive in health care? YOU should increase her gabapentin to > 2400 mg/d! Why? Probability of benefit near zero, toxicity certain You re gonna take these 23 new pills, and It s gonna be great (fire and fury)! 15

16 Practical tricks of the trade 1. Rank medication list quickly by priority: probably useful Irrelevant or uncertain probably/potentially harmful 2. Recognize likely drug interactions (kinetic or dynamic); avoid potentially dangerous ones e.g. multiple drugs that slow heart rate or impair K+ excretion or GFR 3. Use T ½ elim to plan safe deprescribing see example 4. Challenge rather than worship unsupported, impractical, or potentially dangerous prescriptions originated by specialists. 16

17 Plea for indications (purpose) Reason Indication-based discharge prescription by FAX northern BC, 2017 If a tiny hospital can do this why can t we? 17

18 Ranking drugs for symptoms by benefit It should be easy for symptoms if we probe for straightforward answers and listen, e.g.: That one really helps me They started them all at once, so I can t tell! I never liked that one, but I really like my WHY DON T WE ASK MORE OFTEN? 18

19 Case 2: How would YOU respond to this situation? 85 y/o hospitalized for alcohol w/d has high BP, osteoporosis, colitis, insomnia, chronic pain, etc. Regular psychotropics: 1. mirtazapine 45 mg/d (h.s.) 2. quetiapine 300 mg/d (h.s.) 3. zopiclone 15 mg/d (h.s.) 4. pregabalin 225 mg/d (divided doses) We will see video in live presentation Other drugs: 1. felodipine 2.5 mg/d 2. telmisartan 80 mg/d 3. T4 25 mcg/d 4. rabeprazole 20 mg/d 5. CaC03 twice/d 6. Vit D 800 units/d 7. risedronate 35 mg/week 8. KCL 8 meq twice/d ASA 6 tablets/d 19

20 Practical tricks of the trade 1. Rank medication list quickly by priority: probably useful Irrelevant or uncertain probably/potentially harmful 2. Recognize likely drug interactions (kinetic or dynamic); avoid potentially dangerous ones e.g. multiple drugs that slow heart rate or impair K+ excretion or GFR or impair the brain! 3. Use T ½ elim to plan safe deprescribing see example 4. Challenge rather than worship unsupported, impractical, or potentially dangerous prescriptions originated by specialists. 20

21 How would YOU respond to this situation? LOOK AGAIN on the right Regular psychotropics: 1. mirtazapine 45 mg/d 2. quetiapine 300 mg/d 3. zopiclone 15 mg/d 4. pregabalin 225 mg/d 1. felodipine 2.5 mg/d 2. telmisartan 80 mg/d 3. T4 25 mcg/d 4. rabeprazole 20 mg/d 5. CaC03 twice/d 6. Vit D 800 units/d 7. risedronate 35 mg/wk 8. KCL 8 meq twice/d ASA 6 tablets/d 21

22 Now that you have seen her, Considering only her psychotropic drugs, would YOU change anything? DRUG STOP REDUCE CONTINUE Mirtazepine 45 mg/d Quetiapine 300 mg/d Zopiclone 15 mg/d Pregabalin 225 mg/d 22

23 Practical tricks of the trade We re about to see her again in a video! 1. Rank medication list quickly by priority: probably useful Irrelevant or uncertain probably/potentially harmful 2. Recognize likely drug interactions (kinetic or dynamic); avoid potentially dangerous ones e.g. multiple drugs that slow heart rate or impair K+ excretion or GFR 3. Use T ½ elim to plan safe deprescribing see example 4. Challenge rather than worship unsupported, impractical, or potentially dangerous prescriptions originated by specialists. 23

24 Case 3: submitted by Manitoba NP 62 y/o man had CABG + 2 stents about 4 years ago Medical history: BPH High BP dyslipidemia GERD Single kidney after childhood trauma Drugs: 1. Clopidogrel 75mg/d 2. ASA 81mg/d 3. Atorvastatin 80mg/d 4. HCTZ 25mg/d 5. Ramipril 10mg/d 6. Metoprolol 25mg bid 7. Ranitidine 150mg bid 8. Finasteride 5mg/d 9. Tamsulosin 0.4mg/d 10. NTG spray (not used) 24

25 Case 3: submitted by Manitoba NP 62 y/o man had CABG + 2 stents about 4 years ago Feels healthy, without chest pain, no dyspnea He quit smoking after MI and is active His LUTS have improved His cholesterol is within normal He would like to stop some drugs Could he stop clopidogrel (Plavix), atorvastatin, ranitidine? 25

26 Can you help him by using a simple resource? or Clopidogrel: ti.ubc.ca/2015/07/31/dual-antiplatelet-therapynet-health-benefit-or-harm/ Atorvastatin: ti.ubc.ca/2013/01/02/high-dose-versus-standarddose-statins-in-stable-coronary-heart-disease/ Ranitidine:? Drugs for BPH: ti.ubc.ca/2006/03/31/benign-prostatichypertrophy-an-update-on-drug-therapy/ Beta blockers after MI or CABG/stent: 26

27 Case 4: You think YOUR life is complicated? Polypharmacy after MVA (frighteningly common) Young woman after car crash (pain): 1. Lansoprazole 20mg/d 2. Atorvastatin 40mg/d 3. Pregabalin 225mg at bedtime If this list doesn t 4. Solifenacin 5mg/d 5. Topiramate 100mg at bedtime 6. Aripiprazole 5mg/d 7. Sertraline 250mg/d 8. Nortriptyline 40mg at bedtime 9. Vortioxetine 20mg at bedtime 10. Trazodone (100mg at bedtime) 11. Zopiclone (7.5mg at bedtime) 12. prn Cyclobenzaprine at bedtime 13. prn: Ketorolac Injectable IM 14. prn hydromorphone 1-2 mg 15. prn Acetaminophen (paracetamol) 16. prn methocarbamol, THC pills, marijuana frighten you, it should! But what to do about it? 27

28 Hopeless situation??? Maybe not - if we challenge EVERYTHING! But if we re not the prescriber, it will require some kind of logic and plan So how much time is one human life worth? 28

29 Let s try ranking by priority quickly! can anyone SHOUT OUT at least 1 to STOP? Psychotropic drugs: For pain? Pregabalin 225mg (? pain) Topiramate 100mg (? pain) Nortriptyline 40mg bedtime Cyclobenzaprine bedtime Ketorolac Injectable Hydromorphone 1-2mg Acetaminophen methocarbamol, THC, MJ For depression? Aripiprazole 5mg/d Sertraline 250mg/d Vortioxetine 20mg/d More psychotropics: For insomnia? Trazodone 100mg at bedtime Zopiclone 7.5mg at bedtime? Nortriptyline 40mg bedtime Drugs? to counter AE: Lansoprazole 20 mg/d Solifenacin 5mg/d Preventive drugs: Atorvastatin 29

30 #4 : develop strong reflex responses to dogma/ignorance alerts Adding a third-generation ( ) will improve his ( ) She needs to start bid I strongly recommend to prevent early death. Dual agent is indicated. Guidelines strongly recommend (Grade A recommendation, weak evidence) 30